In Reply:--We agree with the comments from Pivalizza et al. that patients with hepatic failure and portal hypertension are at risk for aspiration, and that airway management may be impaired with a procedure in the neck. However, Pivalizza et al. appear to imply that general anesthesia is better than conscious sedation and monitored anesthesia care for transjugular intrahepatic portosystemic shunt (TIPS) procedures. The overall complication rate for TIPS is low, with the majority of complications occurring after the procedure. The TIPS procedure is nonoperative. The extent of procedural pain is limited to the puncture wound in the neck and mild pain during dilation of the Wallstent device. The decision for a general anesthetic versus sedation and monitored anesthesia care for a TIPS procedure is made based on the mental status of the patient and the ability to tolerate the procedure without moving, as well as the overall hemodynamic status and ease of airway management. We believe that sedation and monitored anesthesia care is appropriate in select patients, and we would not suggest general anesthesia for all patients undergoing TIPS procedure. In reviewing the last 20 TIPS procedures done at our institution, 50% were done under general anesthesia and 50% were performed using conscious sedation. Two patients receiving conscious sedation were anesthetized during the course of the procedure because they were unable to remain still for the procedure.
Pivalizza et al.'s statement, “advocate-increased anesthesiologist participation for this procedure,” suggests that general anesthesia results in greater anesthesiologist participation. All TIPS procedures at our institution are performed with the participation of an anesthesiology team. Sedation with monitored anesthesia care does not mean less anesthesiologist participation and, therefore, general anesthesia does not mean increased anesthesiologist participation. Our comment regarding “necessary support should inadvertent complications occur” refers to the need for the anesthesiology team to be prepared for anything, which includes emergency airway management, hemodynamic pressor support, and the possibility of massive transfusion in a remote area that typically is devoid of intravenous pumps and fluid warmers.
Lois A. Connolly, M.D., Department of Anesthesiology, Medical College of Wisconsin, Froedtert Memorial Lutheran Hospital, 9200 W. Wisconsin Avenue, Milwaukee, Wisconsin 53226.
(Accepted for publication July 18, 1996.)